Public Policy

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

A new implementation date for the 10th revision of the International Statistical Classification of Diseases coding system (ICD-10) isn't expected to be known until after the November election, says a coding specialist. But hospitalists and others should not take that as a sign to just sit around and wait for a date.

"We're probably not going to hear anything until after the election is finished," says Brenda Edwards, CPC, CPMA, a coding and compliance specialist with Kansas Medical Mutual Insurance Co. and a trainer with AAPC. "The thing that's worrisome, though, is people think this delay we have encountered is a time to sit back and do nothing, but really we’re almost burning money by not doing anything."

An outcry from many physicians led the U.S. Department of Health and Human Services to delay the planned October 2013 implementation date. No new date has been announced.

Edwards urges physicians, billing specialists, and group leaders to use the delay as an opportunity to better prepare for the implementation. She suggests checking with vendors and preparing training programs to help adjust to the new coding initiative, which will quadruple the number of billing codes to 68,000.

"Everyone at this point should still be moving forward," she says.

At the same time, the Centers for Medicare & Medicaid Services (CMS) is seeking public comment on a new version of its ICD-10 readiness assessment. Those interested in weighing in can learn more here.

A new implementation date for the 10th revision of the International Statistical Classification of Diseases coding system (ICD-10) isn't expected to be known until after the November election, says a coding specialist. But hospitalists and others should not take that as a sign to just sit around and wait for a date.

"We're probably not going to hear anything until after the election is finished," says Brenda Edwards, CPC, CPMA, a coding and compliance specialist with Kansas Medical Mutual Insurance Co. and a trainer with AAPC. "The thing that's worrisome, though, is people think this delay we have encountered is a time to sit back and do nothing, but really we’re almost burning money by not doing anything."

An outcry from many physicians led the U.S. Department of Health and Human Services to delay the planned October 2013 implementation date. No new date has been announced.

Edwards urges physicians, billing specialists, and group leaders to use the delay as an opportunity to better prepare for the implementation. She suggests checking with vendors and preparing training programs to help adjust to the new coding initiative, which will quadruple the number of billing codes to 68,000.

"Everyone at this point should still be moving forward," she says.

At the same time, the Centers for Medicare & Medicaid Services (CMS) is seeking public comment on a new version of its ICD-10 readiness assessment. Those interested in weighing in can learn more here.

A new implementation date for the 10th revision of the International Statistical Classification of Diseases coding system (ICD-10) isn't expected to be known until after the November election, says a coding specialist. But hospitalists and others should not take that as a sign to just sit around and wait for a date.

"We're probably not going to hear anything until after the election is finished," says Brenda Edwards, CPC, CPMA, a coding and compliance specialist with Kansas Medical Mutual Insurance Co. and a trainer with AAPC. "The thing that's worrisome, though, is people think this delay we have encountered is a time to sit back and do nothing, but really we’re almost burning money by not doing anything."

An outcry from many physicians led the U.S. Department of Health and Human Services to delay the planned October 2013 implementation date. No new date has been announced.

Edwards urges physicians, billing specialists, and group leaders to use the delay as an opportunity to better prepare for the implementation. She suggests checking with vendors and preparing training programs to help adjust to the new coding initiative, which will quadruple the number of billing codes to 68,000.

"Everyone at this point should still be moving forward," she says.

At the same time, the Centers for Medicare & Medicaid Services (CMS) is seeking public comment on a new version of its ICD-10 readiness assessment. Those interested in weighing in can learn more here.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

On April 17, the U.S. Department of Health and Human Services (HHS) published a proposed rule to delay the compliance date for the International Classification of Diseases, 10th Edition, diagnosis and procedure codes (ICD-10) from Oct. 1, 2013, to Oct. 1, 2014.2

Per HHS, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic healthcare transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HHS proposes that covered entities must be in compliance with ICD-10 by Oct. 1, 2014.

On April 17, the U.S. Department of Health and Human Services (HHS) published a proposed rule to delay the compliance date for the International Classification of Diseases, 10th Edition, diagnosis and procedure codes (ICD-10) from Oct. 1, 2013, to Oct. 1, 2014.2

Per HHS, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic healthcare transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HHS proposes that covered entities must be in compliance with ICD-10 by Oct. 1, 2014.

On April 17, the U.S. Department of Health and Human Services (HHS) published a proposed rule to delay the compliance date for the International Classification of Diseases, 10th Edition, diagnosis and procedure codes (ICD-10) from Oct. 1, 2013, to Oct. 1, 2014.2

Per HHS, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic healthcare transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HHS proposes that covered entities must be in compliance with ICD-10 by Oct. 1, 2014.

Last month, the Food and Drug Administration cleared a test designed to quickly identify a dozen types of bacteria that can lead to bloodstream infections.

The Verigene GP Blood Culture Nucleic Acid Test, developed by molecular diagnostic firm Nanosphere Inc. of Northbrook, Ill., can identify Staphylococcus (including methicillin-resistant S. aureus, or MRSA), Streptococcus, Enterococcus (including vancomycin-resistant enterococci), and Listeria.

"The current standard of treatment is to provide broad-spectrum antibiotics, including some last-line therapies, such as vancomycin, in order to get coverage for everything," says Mike McGarrity, a Nanosphere executive. "With antibiotic stewardship programs in the majority of hospitals, there is an understanding of the overuse of these last-line therapies and the development of resistance."

Currently, blood cultures can take two to four days to identify certain types of bacteria and determine whether any present are resistant to certain therapies. Once a blood culture is positive, the Nanosphere test can identify bacteria and antimicrobial resistance genes in roughly two and half hours. In a pitch that McGarrity believes will resonate with HM groups, he positions the product as a cost-saver that can reduce length of stay (LOS) for hospitalized patients, as physicians don’t have to wait two days for test results. Quicker identification can also lead to lower mortality rates, he says.

McGarrity, who says Nanosphere will submit an application to the FDA this year for a similar rapid-results test for Clostridium difficile and a broad enteric panel, adds that the test is $75 per use. With LOS reduction and cost savings for targeted de-escalated therapies, he says, there is clear value in the test.

"This gets the attention of stakeholders," he says.

Last month, the Food and Drug Administration cleared a test designed to quickly identify a dozen types of bacteria that can lead to bloodstream infections.

The Verigene GP Blood Culture Nucleic Acid Test, developed by molecular diagnostic firm Nanosphere Inc. of Northbrook, Ill., can identify Staphylococcus (including methicillin-resistant S. aureus, or MRSA), Streptococcus, Enterococcus (including vancomycin-resistant enterococci), and Listeria.

"The current standard of treatment is to provide broad-spectrum antibiotics, including some last-line therapies, such as vancomycin, in order to get coverage for everything," says Mike McGarrity, a Nanosphere executive. "With antibiotic stewardship programs in the majority of hospitals, there is an understanding of the overuse of these last-line therapies and the development of resistance."

Currently, blood cultures can take two to four days to identify certain types of bacteria and determine whether any present are resistant to certain therapies. Once a blood culture is positive, the Nanosphere test can identify bacteria and antimicrobial resistance genes in roughly two and half hours. In a pitch that McGarrity believes will resonate with HM groups, he positions the product as a cost-saver that can reduce length of stay (LOS) for hospitalized patients, as physicians don’t have to wait two days for test results. Quicker identification can also lead to lower mortality rates, he says.

McGarrity, who says Nanosphere will submit an application to the FDA this year for a similar rapid-results test for Clostridium difficile and a broad enteric panel, adds that the test is $75 per use. With LOS reduction and cost savings for targeted de-escalated therapies, he says, there is clear value in the test.

"This gets the attention of stakeholders," he says.

Last month, the Food and Drug Administration cleared a test designed to quickly identify a dozen types of bacteria that can lead to bloodstream infections.

The Verigene GP Blood Culture Nucleic Acid Test, developed by molecular diagnostic firm Nanosphere Inc. of Northbrook, Ill., can identify Staphylococcus (including methicillin-resistant S. aureus, or MRSA), Streptococcus, Enterococcus (including vancomycin-resistant enterococci), and Listeria.

"The current standard of treatment is to provide broad-spectrum antibiotics, including some last-line therapies, such as vancomycin, in order to get coverage for everything," says Mike McGarrity, a Nanosphere executive. "With antibiotic stewardship programs in the majority of hospitals, there is an understanding of the overuse of these last-line therapies and the development of resistance."

Currently, blood cultures can take two to four days to identify certain types of bacteria and determine whether any present are resistant to certain therapies. Once a blood culture is positive, the Nanosphere test can identify bacteria and antimicrobial resistance genes in roughly two and half hours. In a pitch that McGarrity believes will resonate with HM groups, he positions the product as a cost-saver that can reduce length of stay (LOS) for hospitalized patients, as physicians don’t have to wait two days for test results. Quicker identification can also lead to lower mortality rates, he says.

McGarrity, who says Nanosphere will submit an application to the FDA this year for a similar rapid-results test for Clostridium difficile and a broad enteric panel, adds that the test is $75 per use. With LOS reduction and cost savings for targeted de-escalated therapies, he says, there is clear value in the test.

"This gets the attention of stakeholders," he says.

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

I believe the hospitalist will be right at the center of the model, along with the PCPs. In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.

—Ken Simone, DO, SFHM, principal, Hospitalist and Practice Solutions

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

I believe the hospitalist will be right at the center of the model, along with the PCPs. In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.

—Ken Simone, DO, SFHM, principal, Hospitalist and Practice Solutions

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

I believe the hospitalist will be right at the center of the model, along with the PCPs. In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.

—Ken Simone, DO, SFHM, principal, Hospitalist and Practice Solutions

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

The year Medicare becomes insolvent, according to the Medicare Trustees Report for 2012, released in April. The date is the same as in the prior year’s report but is eight years later than the trustees believe funds would expire without the provisions contained in the Affordable Care Act to reward efficient, quality care. The trustees, who include the secretaries of the Treasury, Labor, Health and Human Services, and Social Security departments, say Medicare is stable for now, and Medicare expenditures in 2011, at $549 billion, were lower than expected. But action is still needed to secure its long-term future.¹ The report states that Medicare’s Supplementary Medical Insurance Trust Fund is financially balanced, although some critics have offered far less sanguine projections for the future of the Medicare program, based on its annual and cumulative cash shortfalls.

Reference

1. Centers for Medicare & Medicaid Services. The 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/ReportsTrustFunds/downloads/tr2012.pdf. Accessed May 30, 2012.

The year Medicare becomes insolvent, according to the Medicare Trustees Report for 2012, released in April. The date is the same as in the prior year’s report but is eight years later than the trustees believe funds would expire without the provisions contained in the Affordable Care Act to reward efficient, quality care. The trustees, who include the secretaries of the Treasury, Labor, Health and Human Services, and Social Security departments, say Medicare is stable for now, and Medicare expenditures in 2011, at $549 billion, were lower than expected. But action is still needed to secure its long-term future.¹ The report states that Medicare’s Supplementary Medical Insurance Trust Fund is financially balanced, although some critics have offered far less sanguine projections for the future of the Medicare program, based on its annual and cumulative cash shortfalls.

Reference

1. Centers for Medicare & Medicaid Services. The 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/ReportsTrustFunds/downloads/tr2012.pdf. Accessed May 30, 2012.

The year Medicare becomes insolvent, according to the Medicare Trustees Report for 2012, released in April. The date is the same as in the prior year’s report but is eight years later than the trustees believe funds would expire without the provisions contained in the Affordable Care Act to reward efficient, quality care. The trustees, who include the secretaries of the Treasury, Labor, Health and Human Services, and Social Security departments, say Medicare is stable for now, and Medicare expenditures in 2011, at $549 billion, were lower than expected. But action is still needed to secure its long-term future.¹ The report states that Medicare’s Supplementary Medical Insurance Trust Fund is financially balanced, although some critics have offered far less sanguine projections for the future of the Medicare program, based on its annual and cumulative cash shortfalls.

Reference

1. Centers for Medicare & Medicaid Services. The 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/ReportsTrustFunds/downloads/tr2012.pdf. Accessed May 30, 2012.

It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.

Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.¹

This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.

Is 16 the Magic Number?

In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.

“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”

Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.² HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”

“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”

While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.

“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.

Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.

Continuity of Care

A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.

“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.

New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”

It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.

—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president

Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”

Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.

Hospitalist Opportunity

Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.

“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”

The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
2. Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.

It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.

Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.¹

This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.

Is 16 the Magic Number?

In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.

“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”

Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.² HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”

“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”

While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.

“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.

Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.

Continuity of Care

A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.

“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.

New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”

It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.

—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president

Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”

Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.

Hospitalist Opportunity

Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.

“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”

The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
2. Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.

It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.

Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.¹

This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.

Is 16 the Magic Number?

In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.

“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”

Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.² HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”

“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”

While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.

“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.

Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.

Continuity of Care

A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.

“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.

New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”

It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.

—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president

Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”

Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.

Hospitalist Opportunity

Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.

“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”

The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
2. Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.